GASTROENTEROLOGY CURRICULUMGastroenterology encompasses the evaluation and treatment of patients with disorders of thegastrointestinal tract, pancreas, biliary tract, and liver as well as organs within the abdominal cavity.Rotation on the medical ward services, gastroenterology elective, and in general medicine clinic willprovide training for the resident to develop the wide range of competencies ( i.e., patient care, medicalknowledge, practice based learning and improvement, interpersonal and communication skills,professionalism and systems based practice) necessary for the clinical diagnosis and management ofcommon gastroenterological disorders. This curriculum details these competencies that are addressedduring the gastroenterology elective, showing the graduated skill development a resident shouldachieve as they progress through the 3-year internal medicine residency program.Progressive Learning ObjectivesThe following table details the gastroenterological competencies which a resident is expected toachieve in order to progress to the subsequent training year.Table 1. Progressive Learning Objectives by Competency R-1 R-2 R -3Competency: Patient Care1) Perform a thorough and 1) Efficiently perform a focused, and 1) As in R-2.appropriate history and physical appropriate history and physicalexamination of Gastroenterology examination of Gastroenterolgypatients. patients including detection of subtle findings.2) Synthesize data into a problem list 2) Formulate a diagnostic and 2) As in R-2and differential diagnosis. Formulate therapeutic plan independently,a diagnostic and therapeutic plan incorporating issues of cost, riskwith some supervision. benefit and patient preference into decisions.Competency: Medical Knowledge1) Describe basic pathophysiology, 1) Demonstrate in depth knowledge 1) As in R-2.diagnostic approach and treatment for of pathophysiology, diagnosticcommon gastrointestinal and approach and treatment for commonhepatobiliary disorders1. gastrointestinal and hepatobiliary disorders.2) Generate a basic differential 2) Generate a relevant and complete 2) As in R-2diagnosis for common differential diagnosis for commongastrointestinal complaints and exam gastrointestinal complaints and examfindings2, 3. findings.3) Understand issues related to the 3) As in R-1. 3) As in R-1.initial assessment of patients for livertransplant and initial management ofpatients with a history of organtransplant.4) Familiar with management of 4) As in R-1. 4) As in R-1.nutritional support4.5) Understand appropriate use, 5) In depth knowledge of the 5) As in R-1.indication, interpretation and appropriate use, indication,limitations of diagnostic studies interpretation and limitations ofrequired for the practice of diagnostic studies required for thegastroenterology 5. practice of gastroenterology.Table 1. Progressive Learning Objectives by Competency, continued. 1
Competency: Interpersonal and Communication Skills1) Develop effective listening and 1) Use skills of listening and 1) As in R-2.communication skills in the care of counseling to develop a therapeuticpatients and their families. relationship with patients and their families.2) Effectively and respectfully 2) As in R-1. 2) As in R-1.communicate with nursing andancillary staff.3) Develops skills of medical record 3) Efficient and concise medical 3) As in R- 2.documentation that is comprehensive, record documentation that islegible and accurate. comprehensive, legible and accurate.4) Develop skills to counsel patients 4) Effectively counsel patients on 4) As in R-2.on colorectal cancer screening risks colorectal cancer screening risks andand benefits. benefits.Competency: Professionalism1) Professional appearance and 1) As in R-1. 1) As in R-2.demeanor.2) Trustworthy, reliable, and honest. 2) As in R-1. 2) As in R-2.3) Respectful of patient autonomy 3) As in R-1. 3) As in R-2.and patient rights in regards tomedical decisions.4) Effectively care for patients of 4) As in R-1. 4) As in R-2.diverse backgrounds, physiologicfunction, health status, and values.5) Maintain patient confidentiality 5) As in R-1. 5) As in R-2.6) Understand how to inform patients 6) As in R-1. 6) As in R-2.about the risks and benefits oftherapeutic interventions related togastroenterology to obtain informedconsent for procedures andtreatments.Competency: Practice Based Learning and Improvement1) Recognize and acknowledge 1) Recognize, learn from, and 1) As in R-2.errors. analyze errors. Seek to implement change on a systems level to prevent error.2) Utilize appropriate information 2) Develop expertise in usage of 2) As in R-2technology to manage and acquire information technology to access andrelevant patient specific information. manage information in support of patient care.3) Familiar with practice guidelines 3) Effectively implement appropriate 3) As in R-2.relevant to the evaluation and guidelines in the evaluation andmanagement of gastrointestinal management of gastrointestinaldisorders. disorders.Table 1. Progressive Learning Objectives by Competency, continued.Competency: Practice Based Learning and Improvement, continued. 2
4) Familiar with principles of 4) Appropriately apply principles of 4) As in R-2.evidence based medicine. evidence based medicine to answer clinical questions and guide care of Gastroenterology patients.Competency: Systems Based Practice1) Familiar with roles of social 1) Skilled physician leader in work 1) As in R-2.workers, discharge planners, home with ancillary team members tonursing, hospice, and billing provide for needs of patient.coordinators.2) Familiar with role of physician 2) Effective advocate for patient 2) As in R-2.advocate for patient within health within larger health care system.care system.3) Familiar with issues of risk 3) Incorporate knowledge of risk 3) As in R-2.management, quality improvement management, quality improvementand cost-effective medical care. and cost-effective medical care into patient care.4) Familiar with processes of safe 4) Skilled in the processes of safe and 4) As in R-2.and effective”hand off” of care effective “hand off” of care amongamong physicians. physicians.Teaching MethodsDuring the gastroenterology elective, residents learn these skills through1) Attending supervision of resident activities in patient care in the Gastroenterology Attending’s office and endoscopy suite.2) Teaching rounds for inpatient Gastroenterology consultations on the wards;3) Recommended reading as detailed in the appendix to this document.Residents will also develop many of the gastroenterology related competencies through rotation on themedical ward services and in general medicine clinic. Residents will also learn gastroenterologyrelated skills through4) Consultation with specialists including the surgeon, pathologist and radiologist to review specific cases.5) Conferences including morning report and noon conferenceLines of ResponsibilityDuring the Gastroenterology elective month, residents will report directly to the GastroenterologyAttending for supervision of all patient care.EvaluationResidents are evaluated through Attending feedback to residents on strengths and weaknessesthroughout the rotation, attending written evaluations at the end of the monthly rotation, Mini-CEXbedside evaluation tool, and evaluation forms, and the In-Training Exam.Appendix ARecommended ReadingHarrisons Principles of Internal Medicine. 3
Cecil Textbook of Medicine.Sleisenger and Fordtrans Gastrointestinal and Liver Disease: Pathophysiology/Diagnosis/Management.Yamada’s Textbook of Gastroenterology.Yamada’s Gastroenterology/Atlas.MKSAPOn-line Resources• UptoDate• MDConsult• Practice guidelines• American Gastroenterologic Association - www.gastro.org (links to ACG, ASGE, AASLD)Residents should review Annals of Internal Medicine for recent Updates in Gastroenterology andHepatology section as well as ACP journal club for pertinent articles. 4
1 Understand appropriate use of the following interventions: (a) TIPS, (b) speech pathology, (c) esophageal dilation, (d)psychiatric/psychologic evaluation and treatment, (e) iron therapy, erythropoietin and transfusion.2 Develop an approach to patients presenting the following symptoms or signs: (a) abdominal bloating or distention, (b)acute and chronic abdominal pain, (c) abnormal liver function tests, (d) anorectal discomfort, bleeding, or pruritis, (e)anorexia or weight loss, (f) ascites, (g) biliary colic, (h) constipation, (i) diarrhea, (j) dysphagia or odynophagia, (k) earlysatiety, (l) excess intestinal gas, (m) fecal incontinence, (n) gastrointestinal bleeding, (o) heartburn, (p) hematemesis, (q)iron deficiency anemia, (r) jaundice, (s) malnutrition, (t) melena, (u) nausea or vomiting, and (v) noncardiac chest pain3 Recognize symptoms and signs, differential diagnosis and management of the following disease processes: (a)achalasia, (b) alcoholic liver disease and cirrhosis, (c) alpha-1 antitrypsin deficiency, (d) anal fissure, (e) autoimmunehepatitis, (f) Barrett’s esophagus, (g) celiac sprue, (h) cholecystitis, (i) cholangitis, (j) colonic polyps, (k) diverticulosisand diverticulitis, (l) dyspepsia, (m) gallstone disease, (n) gastritis and peptic ulcer disease, (o) gastroesophageal refluxdisease, (p) gatroparesis, (q) GI manifestations of AIDS, (r) hemachromatosis, (s) hemorrhoids, (t) hepatitis, (u)hepatorenal syndrome, (v) inflammatory bowel disease (Crohn’s, ulcerative colitis, microscopic colitis, pouchitis), (w)irritable bowel syndrome, (x) acute and chronic liver failure and associated complications (ascites, spontaneous bacterialperitonitis, encephalopathy, portal hypertension), (y) malabsorption, (z) mesenteric insufficiency, (aa) neoplasm –esophagus, stomach, biliary tract, pancreas, liver, small bowel and colorectal, (bb) pancreatitis – acute, chronic,pseudocysts, (cc) peritionitis, (dd) primary biliary cirrhosis, (ee) primary sclerosing cholangitis, (ff) steatohepatitis, (gg)upper and lower gastrointestinal bleeding, (hh) varices, (ii) venoocclusive disease, and (jj) Wilson’s disease.4 Knowledge of management of nutritonal support includes the following:.(a) Know normal body metabolism/caloricrequirements and understand the changes that occur with stress/disease/starvation; (b) Know how to calculate ideal bodyweight; (c) Develop competence in the management of obesity; (d) Understand indications for enteral and parenteralnutrition, (e) Know methods of enteral nutrition (nasogastric/nasojejunal feedings, PEG, PEG-J, jejunostomy tubes); and(f) Know how to order and adjust peripheral and central parental nutrition.5 Understand appropriate use, interpretation and limitations of the following diagnostic studies: (a) complete blood countwith indices, (b) chemistries, (c) liver function tests – recognition of patterns, (d) famylase and lipase, (e) B12 and folatelevels, (f) stool guaiac, (g) stool studies: fecal leukocytes, ova and parasites, culture, fat, electrolytes, osmolality, (h)hepatitis serologies, (i) blood tests for autoimmune, cholestatic and genetic liver diseases, (j) assays for Helicobacterpylori, (k) tumor markers, (l) serum gastrin level, (m) abdominal x-ray, (n) upper and lower GI series, (o) abdominal CTscan, (p) gastric emptying study, (q) gall bladder radionuclide (HIDA) scan, (r) liver spleen scan, (s) WBC scan, (t)bleeding scan, (u) PET scan, (v) abdominal ultrasound, (w) endoscopic ultrasound, (x) magnetic resonancepancreatography, (y) mesenteric arteriography, (z) upper and lower endoscopy with/without biopsy, (aa) endoscopicretrograde pancreatography, (bb) liver biopsy, (cc) 24 hour esophageal pH monitoring, (dd) esophageal and anorectalmanometry, (ee) swallowing study, (ff) electrogastrogram, (gg) small bowel absorption tests, (hh) lactose and hydrogenbreath tests, (ii) laxative screen, and (jj)Schilling test.